Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Diagnosis and Management Experience from a Spanish Multicenter Registry

Abstract

Background: Severe postprandial hypoglycemia after bariatric surgery is a rare but invalidating complication. Our aim was to describe the different tests performed for its diagnosis and their outcomes as well as the response to the prescribed pharmacological and surgical treatments.

Methods: Multicenter, retrospective systematic review of cases with recurrent severe postprandial hypoglycemia.

Results: Over 11 years of follow-up, 22 patients were identified. The test most used to provoke hypoglycemia was the oral glucose load test followed by the mixed meal test which was the least standardized test. With pharmacological treatment, 3 patients were symptom-free (with octreotide) and in 12 patients hypoglycemic episodes were attenuated. Seven patients had persistent hypoglycemic episodes and underwent surgery. Partial pancreatectomy was performed in 3 patients who had positive selective arterial calcium stimulation, and nesidioblastosis was confirmed in 2 patients. Reconversion to normal anatomy was performed in 3 patients, and 1 patient underwent a resection of the 'candy cane' roux limb, with resolution of hypoglycemia in all cases.

Conclusions: There is high heterogeneity in the evaluation and treatment options for postoperative hypoglycemia. In patients that do not respond to pharmacological treatment, reconstruction of gastrojejunal continuity may be the safest and most successful procedure.

Fig. 1

Continuous glucose monitoring pre-pharmacological treatment. Each line represents an individual day. Y-axes represent glucose (mg/dl), X-axes represent hour of the day. Glucose values below 50 mg/dl are indicated in red and they represent 8% of all glycemic values.

Fig. 2

Continuous glucose monitoring under octreotide treatment. Each line represents an individual day. Y-axes represent glucose (mg/dl), X-axes represent hour of the day. Glucose values below 50 mg/dl are indicated in red. Only one value of glucose below 50 mg/dl was detected. On the contrary, due to side effects of the medication, hyperglycemia (glucose > 150 mg/dl) was detected on a few ocasions.

Fig. 3

Continuous glucose monitoring after revisional surgery. Each line represents an individual day. Y-axes represent glucose (mg/dl), X-axes represent hour of the day. Six months after the resection of the ‘candy cane’ roux limb no hypoglycemia was observed.